Fibromyalgia Syndrome: An Overview of Pathophysiology, Diagnosis and Management

Firdous Jahan,¹ Kashmira Nanji,² Waris Qidwai,² Rizwan Qasim¹

Abstract

Fibromyalgia Syndrome (FMS) is a chronic condition causing pain, stiffness, and tenderness of the muscles, tendons, and joints. It is also characterized by restless sleep, tiredness, fatigue, anxiety, depression, and disturbances in bowel functions. The etiology of fibromyalgia remains unknown, but recent advances and discoveries have helped to unravel some of the mysteries of this disease. Research highlights some of the biochemical, metabolic, and immunoregulatory abnormalities associated with fibromyalgia. Management of FMS at the present time is very difficult as it has multiple etiological factors and psychological predispositions; however, a patient centered approach is essential to handle this problem.

Keywords: Fibromyalgia; Clinical features; Quality of life; Pathophysiology and management of fibromyalgia.

Immunophenotyping of HPV Types 16 and 18 among Sudanese Patients with Oral Lesions

Ibrahim A. M. Ginawi^1*, Ebtihag A. Mahgoub², Hussain G. Ahmed²

Abstract

Objective: The aim of this study was to screen patients with oral lesions for the presence of Human Papilloma Virus (HPV) types 16 and 18.

Methods: Sixty patients aged between 11-80 years with a mean age of 46 years were examined using immunohistological techniques. All samples were retrieved from RICK during the period from August 2009 to August 2010. Out of 60 patients, 50 had Oral Squamous Cell Carcinomas (OSCCs) and the remaining ten had benign oral lesions, included as internal control.

Results: Of the 50 patients with OSCCs, 10 (20%) showed positive immunohistochemical results for HPV types 16 and 18 of which 50% were detected among males and 50% were demonstrated among females. The ten positive findings were Immunophenotyped as follows: five were positive with HPV type 16, four with type 18 and one was positive for HPV types 16 and18. All patients with benign oral lesions were negative for HPV immunohistochemistry.

Conclusion: The study suggests the role of HPV 16 and 18 in the etiology of oral cancers in different parts of Sudan. However, the use of molecular techniques such as PCR are needed to confirm the results of immunohistochemistry in the role of the HPV in developing of OSCC in Sudan.

Clinical Features and Outcome of 65 Laboratory Confirmed Cases of H1N1 in Muscat, Sultanate of Oman

Sumant Pajankar*, Salim Said Al Qassabi, Saud Mohamed Al Harthi

Abstract

Objectives: Responding to Pandemic Influenza A (H1N1) virus alert in 2009, Ministry of Health (MoH), Sultanate Of Oman arranged task force to deal with the emergency. MOH published articles in newspapers, prepared guidelines and hospitals were assigned to admit patients of H1N1. All the patients suspected of H1N1 were admitted and isolated as per the guidelines. This report describes clinical features and outcomes of 65 laboratory confirmed cases of H1N1 in Muscat, Sultanate of Oman.

Methods: From July to October 2009, 101 cases suspected of suffering from Pandemic Influenza A (H1N1) virus were admitted and isolated in Al Nahdha Hospital in Muscat. All the patients on admission were tested for H1N1, by real time reverse transcriptase polymerase chain reaction (RT-PCR). Immediately on admission, all of them were treated with Oseltamivir and antibiotics.

Results: Of the 65 confirmed cases of H1N1, 53.84% were males. Age of patients varied from 14 to 60 years, while 53.7% were aged between 31 to 55 years. Results showed that 70.8% had underlying co-morbidity; among which diabetes mellitus and respiratory illness were common. The most common presenting symptoms were fever (95%) and cough (94%). Also, 20% of the patients had leucopenia and 10.8% leucocytosis. Deranged LFT was observed in 26 (42.6%) of cases while 14 (21.5%) had hypokalemia. One patient (0.01%) with underlying severe co-morbidity died. Two patients (3.1%) had ARDS (Acute Respiratory Distress Syndrome); both recovered. Radiological infiltration was documented in 84.6% of cases, with lower zone involvement as the common finding. Hospital stay was between 1 to 12 days, 49.2% of patients were discharged within 3 days.

Conclusion: Mainly adult population was affected during this epidemic. H1N1 infection can lead to severe illness. Incidence of H1N1 was higher in patients with underlying co-morbidity. Timely intervention and administration of Oseltamivir may need to be modified.

Predictive Value of a 4-Hour Accelerated Diagnostic Protocol in Patients with Suspected Ischemic Chest Pain Presenting to an Emergency Department

Mamatha P.R. Rao^1*, Prashanth Panduranga², Mohammed Al-Mukhaini², Kadhim Sulaiman², Mahmood Al-Jufaili¹

Abstract

Objectives: Currently recommended risk stratification protocols for suspected ischemic chest pain in the emergency department (ED) includes point-of-care availability of exercise treadmill/nuclear tests or CT coronary angiograms. These tests are not widely available for most of the ED’s. This study aims to prospectively validate the safety of a predefined 4-hour accelerated diagnostic protocol (ADP) using chest pain, ECG, and troponin T among suspected ischemic chest pain patients presenting to an ED of a tertiary care hospital in Oman.

Methods: One hundred and thirty-two patients aged over 18 years with suspected ischemic chest pain presenting within 12 hours of onset along with normal or non-diagnostic first ECG and negative first troponin T (<0.010 μg/l) were recruited from September 2008 to February 2009. Low-probability acute coronary syndrome (ACS) patients at 4-hours defined as absent chest pain and negative ECG or troponin tests were discharged home and observed for 30-days for major adverse cardiac events (MACE) (Group I: negative ADP). High-probability ACS patients at 4-hours were defined by recurrent or persistent chest pain, positive ECG or troponin tests and were admitted and observed for in-hospital MACE (Group II: positive ADP).

Results: One hundred and thirty-two patients were recruited and 110 patients completed the study. The overall 30-day MACE in this cohort was 15% with a mortality of less than 1%. 30-days MACE occurred in 8/95 of group I patients (8.4%) and 9/15 of the in-hospital MACE patients in group II. The ADP had a sensitivity of 52% (95% CI: 0.28-0.76), specificity of 93% (0.85-0.97), a negative predictive value of 91% (0.83-0.96), a positive predictive value of 60% (0.32-0.82), negative likelihood ratio of 0.5 (0.30-0.83) and a positive likelihood ratio of 8.2 (3.3-20) in predicting MACE.

Conclusion: A 4-hour ADP using chest pain, ECG, and troponin T had high specificity and negative predictive value in predicting 30-day MACE among low probability ACS patients discharged from ED. However, 30-day MACE in ADP negative patients was relatively high in contrast to guideline recommendations. Hence, there is a need to establish ED chest pain unit and adopt new protocols especially adding a point-of-care exercise treadmill test in the ED.

Keywords: Emergency department; Accelerated diagnostic protocol; Acute coronary syndrome; MACE; Exercise treadmill test; Chest pain unit.

Prevalence and Risk Factors of Diabetic Nephropathy in Omani Type 2 Diabetics in Al-Dakhiliyah Region

Abdulhakeem Hamood Alrawahi^1*, Syed Gauhar A. Rizvi², Dawood Al-Riyami³, Zaher Al-Anqoodi⁴

Abstract

Objective: To assess the prevalence and risk factors of diabetic nephropathy among Omani type 2 diabetics in Al-Dakhiliyah region of the Sultanate of Oman.

Methods: A cross-sectional and a case control study designs were used to assess the prevalence and risk factors respectively. For the prevalence study a sample of 699 diabetic subjects were selected randomly from two polyclinics in Al-Dakhiliyah region; Sumail and Nizwa polyclinics. For the case control study, a sample consisting of 215 cases and 358 controls were randomly selected from those who were included in the cross-sectional study. A well designed questionnaire has been used to collect data regarding the disease and risk factors. Data was analyzed using SPSS19 statistical program.

Results: Total prevalence of diabetic nephropathy was calculated as 42.5% (95% C.I: 38.83% - 46.15%). The difference in the prevalence in the two polyclinic catchment area was not significant. The prevalence was significantly higher among males (51.6%) compared to females (36.5%). Crude analysis of the risk factors showed significant association between diabetic nephropathy and the following factors; male gender, decreased literacy, long duration of diabetes mellitus, hypertension, retinopathy, neuropathy, family history of diabetic nephropathy, poor glycemic control (high HbA1c), and hypertriglyceridemia. Multivariate analysis showed the following factors to be independent risk factors; male gender, decreased literacy, long duration of diabetes, family history of diabetic nephropathy and poor glycaemic control (high HbA1c).

Conclusion: The prevalence of diabetic nephropathy in this study was 42.5% and the significant risk factors associated with it included male gender, decreased literacy, long duration of diabetes, family history of diabetic nephropathy and poor glycemic control (high HbA1c).

Assessment of Educational Environment of Surgical Theatre at a Teaching Hospital of a Saudi University: Using Surgical Theatre Educational Environment Measures

Mona Faisal Al-Qahtani^1* and Mona Al-Sheikh²

Abstract

Objectives: This study was aimed to determine how medical interns perceive the important factors of the learning environment the surgical theatre at the teaching hospital of the medical school, University of Dammam (UoD). The study also investigated the relationships between the learning environment and academic achievements. Finally, it determined the role and significance of gender on the above perceptions and relationships.

Methods: The Surgical Theatre Educational Environment Measure (STEEM) was used to identify the perceptions of interns on the most important factors prevalent in the surgical theatre as an educational environment. STEEM was administered to all interns during the period of June-September 2009. Ninety-one out of 145 students completed the questionnaire representing a response rate of 63%. Non-parametric statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) Version 17.

Results: The STEEM was shown to be internally consistent for the assessment of the overall educational environment in the surgical theatre of UoD. The overall STEEM mean score was 110. For male and female students, the mean scores were 114 and 107 respectively. There were statistically significant gender differences in the perceptions of "learning opportunities" and "teaching and training". Females rated these subscales lower than males. There were no significant associations between academic achievements and perceptions of the educational environment.

Conclusion: The interns perceived the learning environment of the surgical theatre as less than satisfactory. In comparison with the males; the perception of the females was less positive, particularly in the areas of learning opportunities, and teaching and training. The study also revealed some other problematic areas in the learning environment of surgical theatre of the teaching hospital of UoD. The results imply that there is much room for improvement. They also indicate that equal opportunities for learning and training should be given to both sexes.

Keywords: Surgical Theatre Educational Environment Measure (STEEM); Interns; Learning Environment; Medical Education; Saudi Arabia.

Hyperhomocysteinemia in HIV-Infected Individuals: Correlation of a Frequent Prothrombotic Factor with CD4+ Cell Count

Alireza Abdollahi^1*, Tahereh Sanaei Shoar²

Abstract

Objective: This study was aimed at providing an analysis of the correlation between CD4/CD8 counts and some coagulation factors in HIV-Positive Iranian patients.

Methods: A case-control study on 58 HIV-infected patients and control group (58 healthy individuals). Patients and controls were matched for sex and age. In this study, several blood parameters were measured in 58 HIV-infected patients and the controls. Laboratory data were then measured including hemoglobin, platelets, homocysteine, serum levels of IgM and IgG antiphospholipid antibodies (aPL), IgM and IgG anticardiolipin antibotdies (aCL), and CD4⁺ and CD8⁺ cell count.

Results: The HIV-infected patients, compared to healthy controls, showed a significant decline in platelets, CD4 count and CD8 count (p<0.0001), and an increase of homocysteine (p<0.0001) and IgG aPL levels (p<0.0001). No statistical difference was found between patients with CD4 count £200 and CD4 count >200 in the evaluated variables.

Conclusion: The results showed that thrombophilic abnormality in the form of hyperhomocysteinemia is more frequent in HIV-infected patients and should be considered by clinicians in view of an early diagnosis of the hypercoagulability state to prevent thrombotic complications.

Screening for Cryptococcal Antigenemia in Anti-Retroviral Naïve AIDS Patients in Benin City, Nigeria

Favour Osazuwa^1*, John Osilume Dirisu², Patrick Evbaguehita Okuonghae³, Ose Ugbebor⁴

Abstract

Objectives: Cryptococcus neoformans is the most incriminated fungal pathogen causing meningitis in acquired immune deficiency syndrome (AIDS) patients, and is known to constitute a major cause of deaths in AIDS patients. This study thus aimed to determine the baseline sero-prevalence of Cryptococcus neoformans infection in anti-retroviral naïve (ART-naïve) AIDS patients using the serum Cryptococcal antigen (crag) detection method. Baseline effect of variation in CD4 counts, as well as sex and age with sero-positivity for crag were also determined.

Methods: This descriptive cross-sectional study included 150 (61 males and 89 females) ART-naïve AIDS patients attending the Human Immunodeficiency Virus clinic (HIV) at the University of Benin Teaching hospital, Benin City, Nigeria, within the period from February 2011- July 2011. Forty (18 males and 22 females) HIV positive outpatients with CD4 counts >200 cells/µl who were ART-naive were recruited and used as controls. The sero-prevalence of crag in the patients and the control group was measured using the cryptococcal antigen latex agglutination system (CALAS) (Meridian Bioscience, Europe) and CD4 counts were measured using flow cytometry (Partec flow cytometer, Germany).

Results: Of the 150 ART-naïve AIDS patients with CD4 counts £200 cells/µL; 19 (12.7%) were positive for serum Cryptococcal antigen. ART-naïve AIDS patients with CD4 count £50 cells/µl had the highest prevalence of serum crag. Lower CD4 counts were significantly associated with positivity for serum crag (p<0.001). Age and sex had no significant effect on the sero-positivity for serum crag. One (2.5%) of the controls was sero-positive for crag. Thus, serum crag was significantly associated with AIDS but not with HIV (p<0.001).

Conclusion: This study uncovers a high prevalence of crag in ART- naïve AIDS patients in Benin City. The prevalence of crag was higher in ART-naïve AIDS patients with lower CD4 counts. There is an urgent need to introduce routine screening for crag in ART- naïve AIDS patients in our locality to reduce the rapid mortality from Cryptococcal meningitis which accounts for a majority of the morbidity factor if undiagnosed during ART therapy.

Prevalence of Malaria and Anemia among Pregnant Women Attending a Traditional Birth Home in Benin City, Nigeria

Bankole Henry Oladeinde^1*, Richard Omoregie², Ikponmwosa Odia³, Oladapo Babatunde Oladeinde⁴

Abstract

Objectives: To determine the prevalence of malaria and anemia among pregnant women attending a traditional birth center as well as the effect of herbal remedies, gravidity, age, educational background and malaria prevention methods on their prevalence.

Methods: Blood specimens were collected from 119 pregnant women attending a Traditional Birth Home in Benin City, Nigeria. Malaria parasitemia was diagnosed by microscopy while anemia was defined as hemoglobin concentration <11 g/dL.

Results: The prevalence of malaria infection was (OR=4.35 95% CI=1.213, 15.600; p=0.016) higher among primigravidae (92.1%). Pregnant women (38.5%) with tertiary level of education had significantly lower prevalence of malaria infection (p=0.002). Malaria significantly affected the prevalence of anemia (p<0.05). Anemia was associated with consumption of herbal remedies (OR=2.973; 95% CI=1.206, 7.330; p=0.017). The prevalence of malaria parasitemia and anemia were not affected by malaria prevention methods used by the participants.

Conclusion: The overall prevalence of malaria infection and anemia observed in this study were 78.9% and 46.2%, respectively. Higher prevalence of malaria infection was associated with primigravidae and lower prevalence with tertiary education of subjects. Anemia was associated with consumption of herbal remedies. There is urgent need to control the prevalence of malaria and anemia among pregnant women attending traditional birth homes.

Kirner’s Deformity Misdiagnosed as Fracture: A Case Report

Saifullah Khalid*, Mohd Khalid, Samreen Zaheer, Ibne Ahmad, Ekram Ullah

Abstract

Kirner`s deformity or dystelephalangy is a rare entity which presents with painless, progressive, bilateral radiovolar curving of the terminal phalanges of the little fingers. It is a clinicoradiological diagnosis. Herein, we present a case where the patient was being treated as having a fracture of the distal phalanx because of misdiagnosis of Kirner`s deformity. Given the rarity of the deformity, we believe it useful to present our case report as a contribution to the literature.

Keywords: Kirner`s deformity; Fifth; Little finger; Radio-volar angulation.

Hats Off to HIT: A Case Report

Akhwand Shakeel Ahmad^1*, Dhia Jaber Al-Layla², Manjula Dhinakar³

Abstract

Thrombocytopenia is a well- recognized complication of heparin therapy. The diagnosis is mostly clinical and the main value of laboratory testing is in excluding the diagnosis. We describe here a patient with stroke who had aspiration pneumonia leading to sepsis. She developed atrial fibrillation and received heparin which had to be stopped prematurely due to melena. Within 5 days of heparin, she had thrombocytopenia which was heparin-induced thrombocytopenia (HIT), but the diagnosis was missed initially as heparin was no longer on the drug chart.

Oral Lesion as the first Clinical Presentation in Sarcoidosis: A Case Report

Abdul Rahman S. Al-Azri^1*, Richard M. Logan¹, Alastair N. Goss²

Abstract

Sarcoidosis is a common multi-system disease characterized histolopathologically by the formation of non-caseating granulomas in the affected tissues. The oral involvement of sarcoidosis is relatively rare with less than 70 reported cases in literature while an oral lesion as the initial presenting sign is even less common. Oral lesions of sarcoidosis may mimic the lesions of other serious systemic diseases including Crohn’s disease and tuberculosis as well as lesions localized to the orofacial region such as orofacial granulomatosis. This report presents a case of non-progressive sarcoidosis where the initial presenting symptom was a lesion in the buccal vestibule attached to the gingivae. A brief review of the pathology and clinical features is also presented.

Palmar Nerve Sheath Myxoma: A Case Report

Amany Fathaddin, Rehab Fatani

Abstract

Nerve sheath myxoma is a rare benign tumor of the peripheral nerves. It typically presents as a painless, firm, and slow growing nodule with a predilection for extremities mostly fingers and knees. Microscopically, it has characteristic multilobules of spindle cells in an abundant myxoid stroma. The cells are strongly positive for S-100 protein. However, this rare tumor is usually misdiagnosed as other more common benign neuronal tumors. This report describes a rare case of nerve sheath myxoma involving the palmar surface of a 23-year-old female. Clinically, it was diagnosed as a fibroma. It was excised and the final diagnosis was made after histopathological and comprehensive immunohistochemical examination of the specimen. The clinicopathological features of this rare tumor and its important differential diagnoses are discussed along with a brief review of the literature.

Keywords: Nerve sheath myxoma; Palmar nodule.

Pressure Sore at an Unusual Site- the Bilateral Popliteal Fossa: A Case report

Kamal Kataria¹*, Sushma Sagar², Manish Singhal², Rajni Yadav³

Abstract

Pressure sore is tissue ulceration due to unrelieved pressure, altered sensory perception, and exposure to moisture. Geriatric patients with organic problems and patients with spinal cord injuries are the high-risk groups. Soft tissues over bony prominences are the common sites for ulcer development. About 95% of pressure ulcers occur in the lower part of the body. Ischial tuberosity, greater trochanter, sacrum and heel are common sites. In addition to these, pressure sores at unusual sites like nasal alae, malar eminences, cervical region and medial side of knee have also been described. Only 1.6% of the patients present with sores in areas outside the pelvis and lower extremity. In a paraplegic patient, pressure sores are usually over extensor surface of knee and heel but pressure ulcer over popliteal fossa are extremely rare. We herein report a case of a 36-years-old diabetic and paraplegic male, who presented with multiple bed sores involving the sacral area, heels and bilateral popliteal fossa. Popliteal fossa is an unusual site for pressure sores. Only one similar case has been previously reported in the literature.

Giant Cell Fibroblastoma: A Case Report

Mohd Jaseem Hassan*, Syed Shamshad Ahmad, Mahboob Hasan, Mahfooz Basha, Mohd Fahad Khurram

Abstract

Pressure sore is tissue ulceration due to unrelieved pressure, altered sensory perception, and exposure to moisture. Geriatric patients with organic problems and patients with spinal cord injuries are the high-risk groups. Soft tissues over bony prominences are the common sites for ulcer development. About 95% of pressure ulcers occur in the lower part of the body. Ischial tuberosity, greater trochanter, sacrum and heel are common sites. In addition to these, pressure sores at unusual sites like nasal alae, malar eminences, cervical region and medial side of knee have also been described. Only 1.6% of the patients present with sores in areas outside the pelvis and lower extremity. In a paraplegic patient, pressure sores are usually over extensor surface of knee and heel but pressure ulcer over popliteal fossa are extremely rare. We herein report a case of a 36-years-old diabetic and paraplegic male, who presented with multiple bed sores involving the sacral area, heels and bilateral popliteal fossa. Popliteal fossa is an unusual site for pressure sores. Only one similar case has been previously reported in the literature.

Preparing and Conducting Objective Structured Clinical Examination for Oman Medical Specialty Board R1-R4 Residents

Hamed Al Sinawi*, Marwan Al Sharbati, Yousif Obaid, Nonna Viernes

Abstract

The Objective Structured Clinical Examination (OSCE) has been a common tool of assessment in both undergraduate and postgraduate medicine, and has been reported to have both higher reliability and validity over the oral exam. In addition, another advantage is that it reduces luck by standardizing both examiners and patients. This article describes our experience in organizing and conducting an OSCE for Oman Medical Specialty Board residents in Psychiatry.

Keywords: OSCE; Psychiatry; Postgraduate training.

The Effect of Gag Reflex on Cardiac Sympatovagal Tone

S. Mehran Hosseini¹, Mohsen Jamshir^2*, Alireza Maleki²

Abstract

Objectives: Heart velocity may be influenced by gagging. The medulla oblongata receives the afferents of gag reflex. Neuronal pools of vomiting, salivation and cardiac parasympathetic fibers are very close in this area. So, their activities may be changed by spillover from each other. Using the heart rate variability (HRV) analysis, the effect of gagging on cardiac sympatovagal balance was studied.

Methods: ECG was recorded from 12 healthy nonsmoker volunteer students for 10 minutes in the sitting position between 10 and 11 AM. Gagging was elicited by tactile stimulation of the posterior pharyngeal wall. At 1 kHz sampling rate, HRV was calculated. The mean of heart rate at low and high frequencies (LF: 0.04-0.15; HF: 0.15-0.4 Hz) were compared before and after the stimulus.

Results: The mean of average heart rate, LF and HF in normalized units (nu) and the ratio of them (LF/HF) before and after the gagging were 89.9 ± 3 and 95.2 ± 3 bpm; 44.2 ± 5.8 and 21.2 ± 4; 31.1 ± 5.3 and 39.4 ± 3.8; and 1.7 ± 0.3 and 0.6 ± 0.2 respectively.

Conclusion: Gagging increased heart velocity and had differential effect on two branches of cardiac autonomic nerves. The paradoxical relation between average heart rate and HRV indexes of sympatovagal tone may be due to unequal rate of change in autonomic fiber activities which is masked by 5 minutes interval averaging.